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HomeMy WebLinkAboutMiscellaneous - 95 GREENE STREET 4/30/2018T. - CD O N 0 N ❑C O N ' C ai M M 00 O N U) Wa O C) E p z U o w Za Q • 0 o N '� O N U) 0 O € 00 O Z LL F ° C: m 0 LL 0I.L z o Z Wa) 00 O F- (B o O F— :!.:: a V 7 Q = L O -0 cw m L N W O ow z �° •' Q ° F- w � E m 8" o ` • ca 4-- o E — -0 N W z o W C4 N a) N t (D Lo Z ~ • F- L L �i v, J T. - CD O N 'ate ..... ..... TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING II� Q�e Thiscertifies that.J........................................................................................................ has permission to perform ...............................��'................................................. plumbingJ. in the buildings of ....... ae,....�k..................................................... at ........ ......i.in..5......... Y .. , ort Andover, Mass. Feed., P............. Lic. NoZ.') 3. ........................................................ LUMBING INSPECTOR Check # I 5 7 gv� � I k�- Date................................................. TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION CU,— This certifies that ................................ 1. ............... ......II..........................................:................ has permission for gas i,p stallatio �!�1..�..- . c1� inthe buildings of.....1".I..eti................................................................................. at .........1............ I 2�-• e- ........................................... . N A over, Mass. ......... Fee............. Lic. No. 75'4'S Check # I MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM PLUMBING WORK ( MA DATE PERMIT # I/ CITY _ .ry�r—' -_I -15-( JOBSITE ADDRESS OWNER'S NAME POWNER ADDRESS TEL !jk-_IFAX TYPE OR OCCUPANCY TYPE COMMERCIAL © EDUCATIONAL RESIDENTIAL[ PRINT CLEARLY NEW: RENOVATION: REPLACEMENT:W. PLANS SUBMITTED: YES Ell N0[9 FIXTURES"I FLOOR- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BATHTUB CROSS CONNECTION DEVICE DEDICATED SPECIAL WASTE SYSTEM E __._l (.____ I _.__J ___._I I _ _ _ I .._..__i _____-I _.__-! _. I DEDICATED GAS/OIL/SAND SYSTEM DEDICATED GREASE SYSTEM DEDICATED GRAY WATER SYSTEM DEDICATED WATER RECYCLE SYSTEM DISHWASHER I .____ ._.- ! ___ I . __ I __._I .___._. I _v� _..-_ _.._..__� _.._..J _.____I DRINKING FOUNTAIN FOOD DISPOSER FLOOR IAREA DRAIN .__ INTERCEPTOR (INTERIOR) KITCHEN SINK LAVATORY _..__-_J l ROOF DRAIN SHOWER STALL SERVICE / MOP SINK TOILET URINAL WASHING MACHINE CONNECTION WATER HEATER ALL TYPES _ ( WATER PIPING OTHER -.-__J —_I _-_._._1 __._.. =.j __..._._I _ _I ._._. _4 ..----J _< _ I ......__.I INSURANCE COVERAGE: have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL Ch.142. YES Dq NO _I IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY OTHER TYPE OF INDEMNITY D BOND Q OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER F AGENT SIGNATURE OF OWNER OR AGENT I hereby certify that all of the details and information i have submitted or entered regarding this application ar true nd accurate to the best of my knowledge and that all plumbing work and installations performed under the permit issued for this application will b n co p' nce with ertinent provision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER'S NAME L� �` '�iR+i'tJ I LICENSE # 2ZSt-i SIGNATURE MPOi JPN CORPORATION�J#PARTNERSHIPS#LLC�t#I j COMPANY NAME ` ,ct ; ADDR-E—SS: �,ti� I�►„..� _i CITY �,� , ^'------- - .... _ STATE _ � i ZIP I__1, —.�i TEL -E7AX 2 57y�f € CELL �— pe EMAIL `� ��b 3J n Eli W w LU LL �r www • Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/plum ers. TO BE FILED WITH THE PERMITTING AUTAOPITY. . pinacP Print ] rgariizationllndividual): Name (Business/O Address: (� � L Phone #: k CitylState/Zip: Are you an employer? Check the appropriate box: 1.[] I am a employer with____employees (frill and/or part-time).* have 2. KI am a sole prop partnership comp. ersinsurance rno emdl] gees working forme in any capacity. [No workers* 3.E] I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. have employees and have workers' comp. insurance.t These sub -contractors 6, ❑ We are a corporation and its, officers have exercised their right of exemption per MGL c. have no employees. [No workers' comp. insurance required.] 3& 2 - SI - Type of project (required); 7. [] NdVd6nstzvct[on 8. [] Remodeling 9• EJ Demolition 10 El Building addition I1.❑ Electrical repairs or additions 11KJ.prunabing repairs or additions 13•. [] Ro6f repairs 14.[] Other 152, §1(4), andwe rs must submit anew *Arty applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.dav i Homeowners who ubmit•this affidavit indicating they dditional doingshowing the name of the ub contractorallwork d then hire outside os and state whether q potot thoseentitiess, have k Contractors that check this box must attached employees. If the sub contractors have employees, they must provide their workers' comp. policy number. to er that is providing workers' compensation insurance for my employees. Below is the policy and job site I am an emp y information. Insurance Company Name: Policy # or Self -ins. Lic. #:• Expiration Date: City/State/Zip: Job Site Address:showing the policy number and expiuration. date). Attach a copy of the yvorkers' compensation policy declaration page 500.00 Failure to secure coverage as required under MGL penalties the form of aS OP violational punishable ORDER.Iand a fine of up to $250.00 a and/or one-year imprisonment, as well as civil pen day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance covarar10 vvl)u-- I :dohereby c under apainsand enalties of perjury that the information prova e -Date: �— ` —ISSture: PhoneFF #: 3 Official use only. Do not write in this area, to be completed by city or town off rcial. Permit/License # City or Town' Issuing Authority (circle one):' 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone##: Contact Person: The Commonwealth of Massachusetts _ �:-'. Department of IndustrialAccidents .... I Congress Street, Suite 100 = ' d ~ Boston, MA. 02114-2017 massg ov/dia �r www • Workers' Compensation insurance Affidavit: Builders/Contractors/Electricians/plum ers. TO BE FILED WITH THE PERMITTING AUTAOPITY. . pinacP Print ] rgariizationllndividual): Name (Business/O Address: (� � L Phone #: k CitylState/Zip: Are you an employer? Check the appropriate box: 1.[] I am a employer with____employees (frill and/or part-time).* have 2. KI am a sole prop partnership comp. ersinsurance rno emdl] gees working forme in any capacity. [No workers* 3.E] I am a homeowner doing all work myself [No workers' comp. insurance required.] t 4.0 I am a homeowner and will be hiring contractors to conduct all work on my property. I will ensure that all contractors either have workers' compensation insurance or are sole proprietors with no employees. 5. ❑ I am a general contractor and I have hired the sub -contractors listed on the attached sheet. have employees and have workers' comp. insurance.t These sub -contractors 6, ❑ We are a corporation and its, officers have exercised their right of exemption per MGL c. have no employees. [No workers' comp. insurance required.] 3& 2 - SI - Type of project (required); 7. [] NdVd6nstzvct[on 8. [] Remodeling 9• EJ Demolition 10 El Building addition I1.❑ Electrical repairs or additions 11KJ.prunabing repairs or additions 13•. [] Ro6f repairs 14.[] Other 152, §1(4), andwe rs must submit anew *Arty applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information.dav i Homeowners who ubmit•this affidavit indicating they dditional doingshowing the name of the ub contractorallwork d then hire outside os and state whether q potot thoseentitiess, have k Contractors that check this box must attached employees. If the sub contractors have employees, they must provide their workers' comp. policy number. to er that is providing workers' compensation insurance for my employees. Below is the policy and job site I am an emp y information. Insurance Company Name: Policy # or Self -ins. Lic. #:• Expiration Date: City/State/Zip: Job Site Address:showing the policy number and expiuration. date). Attach a copy of the yvorkers' compensation policy declaration page 500.00 Failure to secure coverage as required under MGL penalties the form of aS OP violational punishable ORDER.Iand a fine of up to $250.00 a and/or one-year imprisonment, as well as civil pen day against the violator. A copy of this statement may be forwarded to the Office of Investigations of the DTA for insurance covarar10 vvl)u-- I :dohereby c under apainsand enalties of perjury that the information prova e -Date: �— ` —ISSture: PhoneFF #: 3 Official use only. Do not write in this area, to be completed by city or town off rcial. Permit/License # City or Town' Issuing Authority (circle one):' 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Phone##: Contact Person: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hare, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enferprise, and including the legal representatives of a deceased employer, or the receivdfor trustee of an individual, partnership, association or other legal entity, employing employees. • However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment b6 deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage r'equiired " Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Pleasb fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub=contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self insurance license number on the appropriate line. - City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant thai must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to burn leaves etc.) said person is NOT required to complete this affidavit. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents 1 Congress Street, Suite 100 Boston, MA 02114-2017 Tel. # 617-727-4900 ext. 7406 or 1-877-MASSAFE Fax # 617-727-7749 Revised 02-23-15 wwwmass.gov/dia _ �•` MASSACHUSETTS UNIFORM APPLICATION FOR A PERMIT TO PERFORM GAS FITTING WORK CITY MA DATE _ PERMIT JOBSITE ADDRESS a-- OWNER'S NAME G,� OWNER ADDRESS TE FAX TYP OR PRINT OCCUPANCYTYPE COMMERCIAL EDUCATIONAL ® RESIDENTIALX CLEARLY NEW: DI D. RENOVATION: REPLACEMENT: PLANS SUBMITTED: YES NO[9 APPLIANCES'l FLOORS- BSM 1 2 3 4 5 6 7 8 9 10 11 12 13 14 BOILER BOOSTER CONVERSION BURNER J COOK STOVE DIRECT VENT HEATER C DRYER (.. �. ... (t �� i. –p - ( �.,_ I . - ( (—,. �I ( __ FIREPLACE FRYOLATOR FURNACE GENERATOR,>�,� GRILLE INFRARED HEATER LABORATORY COCKS MAKEUP AIR UNIT OVEN POOL HEATER ROOM/ SPACE HEATER ROOF TOP UNIT TEST UNIT HEATER _ UNVENTED ROOM HEATER i WATER HEATER�— OTHER I khs INSURANCE COVERAGE have a current liability insurance policy or its substantial equivalent which meets the requirements of MGL. Ch. 142 YES NO IF YOU CHECKED YES, PLEASE INDICATE THE TYPE OF COVERAGE BY CHECKING THE APPROPRIATE BOX BELOW LIABILITY INSURANCE POLICY EA— OTHER TYPE INDEMNITY ®I BOND OWNER'S INSURANCE WAIVER: I am aware that the licensee does not have the insurance coverage required by Chapter 142 of the Massachusetts General Laws, and that my signature on this permit application waives this requirement. CHECK ONE ONLY: OWNER 0 AGENT SIGNATURE OF OWNER OR AGENT hereby certify that all of the details and information I have submitted or entered regarding this application are true a accur o the best y knowledge and that all plumbing work and installations performed under the permit issued for this application will be in cc anc with Pertine ision of the Massachusetts State Plumbing Code and Chapter 142 of the General Laws. PLUMBER-GASFITTER NAME LICENSE # 3 (71 SIGNATURE MP Ej MGF Ej JP ® JGF LPGI0 CORPORATION D]# PARTNERSHIPEl#� � LLC E]#= COMPANY NAME:���1.R-r— ADDRESS Il_:�� CITY S STATEr`1 �k ZIP 3 (,S . TEL FAX��jCELL EMAIL _ _ _. - W Z O W \ U a � � az°� C) y � W } H a Z U w �* W F- Q w WW CO a a LU O > w w N a o a P-( a ice., U J F. a CL . Q cs' � w = w t-- LL UO H °z 0 _ H U W P-4 rA t�7 U' Date.J-:7.j5.>7q.z . ....... TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that .......-J. wfo-( ..... ................ has permission to perform ......1. ak.L4-) ..... ......... wiring in the building of ............... N! �k &. 5 /..................................... . at ...... 9, 5 1 4 e ................... North Andover, Mass. Fee..Y,570 Lic. No. ,�.23 . Pi INSPECMR Check # 0703 " °m N cC -j o" a a w a 1-a •(C a w 0 C7 .� CJ „ o a r � •y c o w O s ca p x y O [ '`'' ti ca � � � W a. ry N N 'y O 'O o'no U ❑ •� y N b0D Q P b V N V U O -'w0 ."' N p O V'aU =1 -S-0 " b. � v0, p O UJ y . o � O O� 0 0 CO U �^ :--• N O „ SO C d U O a C y b c`� O' tq .0 cCC x" 4 O 'c7 ipan o .0 O O bA ti b 0 cd p 0Q U O N C 0' m O ,c yb�!A! V W N Uh-aIV 0 ti C W Ppy �.A r 0 'a 4. U k O O •..i C C Co O O >O b M .0-. •O W bA y •.C] .0 � C r" 3 r � O ti 1y � U N p H C O �. ti ro q Tom•" .`� O ' 'O IR .� o �'� O N y0 N N N R °a[o�abn y o . V ~ cd N p a � N U q �cd„uo mH ° .01 off 0 ti o o�w o 3 0�9 G u o -tio u .� 'C d +. a y _C C d 9 WW y a� •4 N 0 E'l'y •r�i� Ur.. o v El u c N -c" O 'k H•o q 0 0 d o W C4 0' 9 ti O .N ie Cow •E O p O o aGi eq 0 o o N ao IP. o w F+ts L -Commonwealth of Massachusetts Official use only Department of Fire Services PermitNo.- 76� BOARD OF FIRE PREVENTION REGULATIONS [Rev 107]y andeav a lank)Checked , (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINTININKORTYPEALLNFORMATION) Date: 3 — g — ac la City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to 1perform the electrical work described below. Location (Street & Number) 95 Cs r e eeie �r P-,* Owner or Tenant Owner's Address Is this permit in conjunction with a building permit? Yes ❑ P 'de e No X1 (Check Appropriate Box) urpose of Budding CQ 51 nu Utility Authorization No, Existing Service 00 Amps 1,�0 / — Lr! Volts Overhead Undgrd ❑ New U.Service Amps / Volts Overhead F]Undgrd El Number of Feeders and Ampacity Location and Nature of Proposed Electrical Work: No. of Meters No. of Meters 31N3 /00 amp whole 60-0 f' 7.#.*,. -PA l i1 .,.:.._._Li- --- --L--- • _I. No, of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans auum friuy ue waivea py ane inspector Q7 wires. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA / O No. of Luminaires Swimming Pool AboveElIn- ❑ o. o mergency ig ng rnd. rnd. Battery Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS No. of Zones No. of Switches No. of Gas Burners No- of Detection and Initiatin Devices No. of Ranges No, of Air Cond. TotaTons l No. of Alerting Devices No. of Waste Disposers Heat Pump Number.. _Tons : KW No. of Self -Contained Totals: Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers Heating Appliances KW Security Systems: -- No. of Watero. No. No. of Devices or E uivalent Heaters KW Sl Bal as Si ns Ballasts Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent vt ttn;tt: I 1 00 Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: oo (When required by municipal policy.) Work to Start: Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such cov ge is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete FIRM NAME: I C nnJ o .�fa IC LIC. NO.: ao 3 06 Licensee: Rt ChA r A - JSignature LIC. NO.: 310330 E (Ifapplicable, enter "exempt" in the license number line.) Bus. Tel. No. tn03- 300 —27 50 Address: % KI N"Div ?b QUiis0W N.H. 03$465 *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Alt. Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. [ PERMIT FEE: S MEc�TRZ�(.tAJjL�1��'•(Ep'7l�� /y �MjI��TpO.�Y. J...C40 U ��..L1.:17.C.Ct `•'TslOJ.Y f , • • . - pass+'ailed--[ ] �2e-Snspecizon xequzxec�($50.OQ) •- [ j inspectors' cOmMOAts: (cusp ectors' Signature •• no initials) Date z. �7�i�x�TSP�C�czoz�; 'assets [ FaUeci j) e-inspectioxt xe�uixeci ($ 0.00) - [ Inspectors' Coolie (Cnsliectors' Signature -)Io initials) Date " r E7lOUNDE9TS1'ECTXOSy: -[ ] ors' comments: Cluspectors' Signature •- no initials) mate 4.'.INSPECTION—SES ICE: DATE � :°�T EW N&T ±ONA-1, GE 1� : )?asseci -- [ IFailed - [ k�e-inspection required ($50.00) - j Inspectors' commenh: (ibaspectors' Signature •• no initials) bate WSPECTWN •- OTRER Passed [ ) )?Ailed •-• [ )_ ?ate zusp ection required ($50.00) •- [ 7 Oaspectors' coVami.ents: sp ect0rsSignature -)10 initials) date 1) 0 O TAGS :ARE TO BE .BILED OUT AND IEFT ON SITE IF THE AREA TO BE INSPECTED IS NOT .A.CCE9810 E AND A. RE-WSPECTION O)` _$50.00 INTO BE CHARGED. The Commonwealth of Massachusetts Department ofIndustrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Applicant Information ( Please Print Legibly Name (Business/Organization/Individual): 91-el� 1(15 n �12 C�f 1.0 Address: to 1 rl -6h City/State/Zip: NLI5 k) N �3Bb5 Phone #: 663 - 3C0 - a7SO Are you an employer? Check the appropriate box: 1. ❑ I am a employer with 4. ❑ I am a general contractor and I employees (full and/or part-time).* have hired the sub -contractors 2. I am a sole proprietor or partner- listed on the attached sheet ship and have no employees These sub -contractors have working for me in any capacity. workers' comp. insurance. [No workers' comp. insurance 5. ❑ We are a corporation and its required.] officers have exercised their 3. ❑ I am a homeowner doing all work right of exemption per MGL myself. [No workers' comp. c. 152, § 1(4), and we have no insurance required.] t employees. [No workers' comp. insurance required.] Type of project (required): 6. ❑ New construction 7. F1 Remodeling 8. ❑ Demolition 9. ❑ Building addition 10. ® Electrical repairs or additions 11. F1 Plumbing repairs or additions 12.❑ Roof repairs 13. ❑ Other *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. i Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit anew affidavit indicating such. tContractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp. policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL c. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. I do hereby c nde re pains )Xdpaft1eJqfperjury ; that the information provided above is true and correct.Signature: 1ATWA,, Date- Phone #: 603— ',;00—VQ-76_0 Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone #: Information and instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire," express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shallnot because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub-contractor(s) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)" A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or' -permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA. 02111 Tel,, # 617-727-4900 ext 406 or 1-877,7MASSA.FB Revised 5-26-05 Fax # 61.7-727-7749 www.mass.govfdia Date3 TOWN OF NORTH ANDOVER PERMIT FOR GAS INSTALLATION t This certifies that k" 'd, has permission for gas installation ... �rCAle +. �' f''. n ........ . in the buildings off�. t ............. . at S.. t �-� ...� ............ North Andover r,�Mass. Fee . & fol 7. Lic. No. .......................... GAS INSPECTOR Check #i 8104 MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO GASFITTING (Print or Type) n lid/' —,Mass. Date 3 �O City, Town Permit # Building AT: Location_ reGlf: Sr - New Renovation ❑ Plans Submitted Yes ❑ No ❑ Owner's/ t NAme Type of Occupancy: Replacement ❑ SUB—BSMT. BASEMENT 1 ST FLOOR t f 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 8TH FLOOR 7TH FLOOR STH FLOOR Check One: (Print or Type) Certificate: Installing Company Name TnWmannd (lt1 f n -- ® Corp. Address 27 Cherr Street Partnership G ❑ Firm/ Company ilanvers 1'4A 013 Business Telephone Name of Licensed Plumber or Gasfitter —.jos I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owner/Agent I have a current liability insurance policy to include completed operations coverage. ❑ 13y TYPE LICENSE: ignatur Licensed Title ❑ Plumber . Plumber or Gasfitter City/ Town ® Gasfitter ❑ Master d �l APPROVE . (OFFICE US " NLY ❑Journeyman License Number � N � . y F+ kL Z 09 N WR u N C O a W t 1- W W a O u s t- Z W O W.4 o OO Wt 1- .4 0W 11 s u cc 0 a Y6OC iWO>W `~WJW V. W W 2 <W CC N C W W V W t7 = J � O Z WO NW r W W ; i- N m < t 0 0 W o O W i- F- o > o ac > o s x o SUB—BSMT. BASEMENT 1 ST FLOOR t f 2ND FLOOR 3RD FLOOR 4TH FLOOR STH FLOOR 8TH FLOOR 7TH FLOOR STH FLOOR Check One: (Print or Type) Certificate: Installing Company Name TnWmannd (lt1 f n -- ® Corp. Address 27 Cherr Street Partnership G ❑ Firm/ Company ilanvers 1'4A 013 Business Telephone Name of Licensed Plumber or Gasfitter —.jos I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. I have informed the owner or his agent that I do not have liability insurance including completed operations coverage. Signature of Owner/Agent I have a current liability insurance policy to include completed operations coverage. ❑ 13y TYPE LICENSE: ignatur Licensed Title ❑ Plumber . Plumber or Gasfitter City/ Town ® Gasfitter ❑ Master d �l APPROVE . (OFFICE US " NLY ❑Journeyman License Number � The Commonwealth of Massachusetts Department ofIndustrialAccidents Office of Investigations 600 Washington Street Boston, MA 02111 www.mass.gov/dia Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plumbers Name (Business/Organization/Individual): Address: o % 0�,, City/State/Zip:L jA,- -- - S ", h,S e nj OJ 04 Pi'"Evc e Phone #: /* w () -) -k i� Are you an employer? Check the appropriate box: Type of project (required): L ❑ I am a employer with 4. ❑ I am a general contractor and I 6. ❑ New construction employees (full and/or part-time).* have hired the sub -contractors 2. El am a sole proprietor or partner- listed on the attached sheet. �• F1 Remodeling ship and'have no employees These sub -contractors have 8. ❑ Demolition working for me in any capacity. workers' comp. insurance. 9. E] Building addition [No workers' comp. insurance 5. We are a corporation and its required.] officers have exercised their 10. [1 Electrical repairs or additions 3. ❑ I am a homeowner doing all work right of exemption per MGL 11. ❑ Plumbing repairs or additions myself. [No workers' comp. c. 152, § 1(4), and we have no 12. ❑ Roof repairs insurance required.] t employees. [No workers' .13. ❑ Other wc-• /C comp. insurance required.] *Any applicant that checks box #1 must also fill out the section below showing their workers' compensation policy information. T Homeowners who submit this affidavit indicating they aie doing all work and then hire outside contractors must submit anew affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub -contractors and their workers' comp, policy information. I am an employer that is providing workers' compensation insurance for my employees. Below is the policy and job site information. Insurance Company Name:. Policy # or Self -ins. Lic. #: Expiration Date: t� I ?, Ci /State/Zi Cy/t- Job Site Address: 9�f C,,�el, J ty p: Attach a copy of the workers' compensation policy declaration page (showing the policy number and expiration date). Failure to secure coverage as requiredunder Section 25A of MGL c.152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA- for insurance coverage verification. I do hereby cer fy rider tli sins d penalties ofperjury that the information provided above is true and correct. Signature: Official use only. Do not write in this area, to be completed by city or town official. City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other - - Contact Person: Phone Information and Instructions - Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. However the owner of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance, construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shall not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to construct buildings in the commonwealth for any applicant who has not produced -acceptable evidence of compliance with the insurance coverage required" Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to carry workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, not the Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the number listed below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. Please be sure to fill in the permit/license number which will be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit. The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number: The Commonw.ealthofMassac- usetts DDpaxtment of Industrial Accidents Office of Investigations 600 Washington Street Boston., MA 02111 Tei, # 617-727-4900 (wt. 406 or 1-877, MASSA FE Revised 5-26-05 Fax # 617-727-7749 www-Ulass,gov/dia Date. :� .. I :Aq. 4,TOWN OF NORT ANDOVER PERMIT FO LUMBING 4401 ,SSAGMUS� This certifies that ... j�!.C.-.1/.?c :47..1� ....1.�.... . ....... . r has permission to perform .....f . S .` .0. w ............... plumbing in the buildings of .�/,/�.�/t.� .� �. /. ................. . at. . f ..G%�*. .� ............ ... , North Andover, Mass. Fee. 3.4A Lic. No. .gKJ.I... ........ PLUMBING INSPECTOR Check # S)—/I' -- {{�� . r , -32,0 .MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS Building I 9 �;- C Type of Occupancy /�,, o Date x411-%rJ �/ e D /uz� , Permit Amount New rl Renovation Replacement13 Plans Submitted Yes No FIXTURES (Print or type) Check one: Certificate Installing Company Name 3.)(-& L6 -� OTC Corp. Address p6cLa= Partner. G Business Telephone 9— K, & Z - 2_� !- Firm/Co. Name ofLicensed Plumber. R e -k) -U u ,P0 --T ) Insurance Coverage: Indicate the type of insurance coverage by checking the appropriate box Liability insurance policy L— Other type of indemnity Bond Insurance Waiver. I, the undersigned, have been made aware that the licensee of this application does noi have any one of the above three insurance ignanue Owner Agent rl I hereby certify that all of the details and information I have submitted (or entered) in above application aV true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massa&etts Staf !Tl biag Co a and Chapter 2 of the General Laws. own ROVED (OFFICE USE ONLY Type of Plumbing License License 1 um er Master ® Journeyman C Date..: 3 % U........ TOWN OF NORTH ANDOVER FO A PERMIT FOR GAS INSTALLATION 3 SACHUSEt i This certifies that � .. .......... . has permission for gas installation ....P ........... in the buildings of .S.Wl.......................... . at ...� s...� t �'.`'... ..... , North Andover, Mass. Fee. -3d..... Lic. No. g �•.. l.� . �-t. �....... . GAS INSPECTOR Check #t i a 7265 ✓IASSACHUSETTS UNIFORM APPLICATON FOR PERMIT TO DO GAS FITTING or print) IwxI'H ANDOVER, MASSACHUSETTS 30�0� Date M13 �/ I C -f'9" Zy ! C) Building Locations Permit # _: 2 O I� Amount S 3 (J Owner's Name A NT4O New❑ Renovation ❑ Replacement M - Plans Submitted ❑ (Print ortype) �tK?��_ ^ L� -jr Check one: Certificate Installing Company Name `� Address L Sit ❑ Parmer. Business Telephone —ZG 63 Firm/Co. Name of Licensed Plumber or Gas Fitter \4 C 1 _�t -t INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑ If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy] Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true ana accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed-Mumber Or Gas Fitter Plumber Gy Q Gas Fitter License I umoer Master Journeyman C. y vi z rn > ` w _ fA W z v 'spa %1 Z .n :z: Z 'C is 'C Z is V n I Z C 7_ ^ y � y is _ y I VI I SUB-BASEM ENT BASEN ENT IST. FLU U R 2ND. FL0UR 3RD. FLOUR 4TIt. FLUOR ST If FLUOR 6T It FLUOR 7T 11. FLUOR 8T If FI.00It (Print ortype) �tK?��_ ^ L� -jr Check one: Certificate Installing Company Name `� Address L Sit ❑ Parmer. Business Telephone —ZG 63 Firm/Co. Name of Licensed Plumber or Gas Fitter \4 C 1 _�t -t INSURANCE COVERAGE Check one: I have a current liability Insurance policy or it's substantial equivalent. Yes ❑ No ❑ If you have checked ves, please indicate the type coverage by checking the appropriate box. Liability insurance policy] Other type of indemnity ❑ Bond ❑ Owner's Insurance Waiver. I am aware that the licensee does not have the Insurance coverage required by Chapter 142 of the Mass. General Laws, and that my signature on this permit application waives this requirement. Check one: Signature of Owner or Owner's Agent Owner ❑ Agent ❑ I hereby certify that all of the details and information I have submitted (or entered) in above application are true ana accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massachusetts State Gas Code and Chapter 142 of the General Laws. By: Title City/Town APPROVED (OFFICE USE ONLY) Signature of Licensed-Mumber Or Gas Fitter Plumber Gy Q Gas Fitter License I umoer Master Journeyman C. /l) . �, e7� Date.................................. TOWN OF NORTH ANDOVER PERMIT FOR WIRING This certifies that ... ,/ ................................ ::............1 ` �:....... has permission to wiring in the building of .L'.: h �. at ................ , North Andover, Mass. Fee ..................... Lic. No............�0.. I- /? ELINSPE Check # A/ / � V A It r Commonwealth of Massachusetts Department of Fire Services BOARD OF FIRE PREVENTION REGULATIONS Official Use Only Permit No. �U d Occupancy and Fee Checked [Rev. 1/07] (leave blank APPLICATION FOR PERMIT TO PERFORM ELECTRICAL WORK All work to be performed in accordance with the Massachusetts Electrical Code (MEC), 527 CMR 12.00 (PLEASE PRINTW INK OR TYPE ALL INFORMATION Date: /0 - 40 - aOO9 City or Town of: NORTH ANDOVER To the Inspector of Wires: By this application the undersigned gives notice of his or her intention to perform the electrical work described below. Location (Street &Number) 9 Greene St:_ Owner or Tenant O rl IHo resch p_i Owner's Address t%s reeve St. Telephone No. 687- 39y3 Is this permit in conjunction with a building permit? Yes ❑ No 0 (Check Appropriate Boz) Purpose of Building (et I efi Ce Utility Authorization No. Existing Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters New Service Amps / Volts Overhead ❑ Undgrd ❑ No. of Meters Number of Feeders and.Ampacity Location and Nature of Proposed Electrical Work: 1115itk W i r t hi /1e W 005-t N l tl n jo- ce t/ 4 ConMetion h0the fnllowinp, table ma be`ivair�d b the Ins ector o Wire No. of Recessed Luminaires No. of Ceil: Susp. (Paddle) Fans s. No. of Total Transformers KVA No. of Luminaire Outlets No. of Hot Tubs Generators KVA No. of Luminaires / Swimming Pool Above ❑ In- ❑ d, rnd. o. o Emergency Lighting Ba5= Units No. of Receptacle Outlets No. of Oil Burners FIRE ALARMS INo. of Zones No. of Switches S No. of Gas Burners o. of Detection and Initiatine Devices No. of Ranges No. of Air Cond. Total Tons No. of Alerting Devices g No. of Waste Disposers eat Pum Totals Number _.� .... _............................. Tons KW ........._. No. of Self -Contained Detection/Alerting Devices No. of Dishwashers Space/Area Heating KW Local ❑ Municipal ❑ Other Connection No. of Dryers No. of Water KW Heaters Heating Appliances KW of No. of Si s Ballasts Signs Security Systems: No. of Devices or Equivalent Data Wiring: No. of Devices or E uivalent No. Hydromassage Bathtubs No. of Motors Total HP Telecommunications Wiring: No. of Devices or E uivalent OTHER: Attach additional detail if desired, or as required by the Inspector of Wires. Estimated Value of Electrical Work: (When required by municipal policy.) Work to Start: /0-(0- A604 Inspections to be requested in accordance with MEC Rule 10, and upon completion. INSURANCE COVERAGE: Unless waived by the owner, no permit for the performance of electrical work may issue unless the licensee provides proof of liability insurance including "completed operation" coverage or its substantial equivalent. The undersigned certifies that such coverage is in force, and has exhibited proof of same to the permit issuing office. CHECK ONE: INSURANCE [9 BOND ❑ OTHER ❑ (Specify:) I certify, under the pains and penalties of perjury, that the information on this application is true and complete. FIRM NAME: RICK O 1N N S"iatJ El GC-n2(C A LIC. NO.: 070 31 G Licensee: R1ew0ao A . JOfw a1V Signature O . LIC. NO.: 34 330 E (If applicable, enter "exempt " in the license /{umber line.) Bus. Tel. No.:603 -300 - oTT_Sa Address: _[e I�Iw1%i5 i at�1 Q� . iLAi STS W 0.14 . 0386S Alt. Tel. No.403 - 38v1 -535y *Per M.G.L c. 147, s. 57-61, security work requires Department of Public Safety "S" License: Lic. No. OWNER'S INSURANCE WAIVER: I am aware that the Licensee does not have the liability insurance coverage normally required by law. By my signature below, I hereby waive this requirement. I am the (check one) ❑ owner ❑ owner's agent. Owner/Agent Signature Telephone No. PERMIT FEE. � � 0 5.. 0 t' 1 www.»wss gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plambers Arinlicant Information Please Print Legibly Mille (Business!Organization/(ndividttal): 1 �' k J d� h STO n 'l✓ `� C+r 1'e Address: NCs57'br3 City/State/Zip: 9L-6lS-M,) OJO 03(?6 Phone#: Are you an employer? Check.the appropriate box: I. ❑ I am. a employer with 4. ❑ I 1N 3.❑ employees (full and/or part-time).* I am a.sole proprietor or partner- ship and. have no employees working for mei any capacity. [No workers' comp. insurance required.] I am a homeowner doing all work myself. [No•workers' comp. insurance required.] t 5. am a general contractor and I have hired the sub -contractors listed on the attached sheet. t These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 1.52, § 1(4), and we have no .employees. [No workers' camp, insurance required..] 306 - Q-7,50 Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition 10. ® Electrical repairs or additions 11.7 Plumbing repairs or additions 12.❑ Roof repairs 13.❑.Other -v-rr••-••••• «�• wf� viz ff , mus[ also nil out the section below showing their workers' eompensation policy information, t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-connactors and their workers • comp, policy information. l am an employer that is providing:workers' compensation insurance for my employees: Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compeusatioo policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ! do hereby ceff3i(y utpder t� pains aid, ena�ties q/Averjury that the information provided above is true and correct •/-1 63 300 ab7S0 O, f rjciat use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: The Commonwealth of Massachusetts k� ! Department of Industrial Accidents Office of Investigations 1.1 iiiit[ �� ,;'a; 600 Washington Street Boston, MA 02111 t' 1 www.»wss gov/dia . Workers' Compensation Insurance Affidavit: Builders/Contractors/Electricians/Plambers Arinlicant Information Please Print Legibly Mille (Business!Organization/(ndividttal): 1 �' k J d� h STO n 'l✓ `� C+r 1'e Address: NCs57'br3 City/State/Zip: 9L-6lS-M,) OJO 03(?6 Phone#: Are you an employer? Check.the appropriate box: I. ❑ I am. a employer with 4. ❑ I 1N 3.❑ employees (full and/or part-time).* I am a.sole proprietor or partner- ship and. have no employees working for mei any capacity. [No workers' comp. insurance required.] I am a homeowner doing all work myself. [No•workers' comp. insurance required.] t 5. am a general contractor and I have hired the sub -contractors listed on the attached sheet. t These sub -contractors have workers' comp. insurance. ❑ We are a corporation and its officers have exercised their right of exemption per MGL c. 1.52, § 1(4), and we have no .employees. [No workers' camp, insurance required..] 306 - Q-7,50 Type of project (required): 6. ❑ New construction 7. ❑ Remodeling S. ❑ Demolition 9. ❑ Building addition 10. ® Electrical repairs or additions 11.7 Plumbing repairs or additions 12.❑ Roof repairs 13.❑.Other -v-rr••-••••• «�• wf� viz ff , mus[ also nil out the section below showing their workers' eompensation policy information, t Homeowners who submit this affidavit indicating they are doing all work and then hire outside contractors must submit a new affidavit indicating such. $Contractors that check this box must attached an additional sheet showing the name of the sub-connactors and their workers • comp, policy information. l am an employer that is providing:workers' compensation insurance for my employees: Below is the policy and job site information. Insurance Company Name: Policy # or Self -ins. Lic. #: Expiration Date: Job Site Address: City/State/Zip: Attach a copy of the workers' compeusatioo policy declaration page (showing the policy number and expiration date). Failure to secure coverage as required under Section 25A of MGL e. 152 can lead to the imposition of criminal penalties of a fine up to $1,500.00 and/or one-year imprisonment, as well as civil penalties in the form of a STOP WORK ORDER and a fine of up to $250.00 a day against the violator. Be advised that a copy of this statement may be forwarded to the Office of Investigations of the DIA for insurance coverage verification. ! do hereby ceff3i(y utpder t� pains aid, ena�ties q/Averjury that the information provided above is true and correct •/-1 63 300 ab7S0 O, f rjciat use only. Do not write in this area, to be completed by city or town official City or Town: Permit/License # Issuing Authority (circle one): 1. Board of Health 2. Building Department 3. City/Town Clerk 4. Electrical Inspector 5. Plumbing Inspector 6. Other Contact Person: Phone #: Information and Instructions Massachusetts General Laws chapter 152 requires all employers to provide workers' compensation for their employees. Pursuant to this statute, an employee is defined as "...every person in the service of another under any contract of hire, express or implied, oral or written." An employer is defined as "an individual, partnership, association, corporation or other legal entity, or any two or more of the'foregoing engaged in a joint enterprise, and including the legal representatives of a deceased employer, or the receiver or trustee of an individual, partnership, association or other legal entity, employing employees. 'however the owner -of a dwelling house having not more than three apartments and who resides therein, or the occupant of the dwelling house of another who employs persons to do maintenance'construction or repair work on such dwelling house or on the grounds or building appurtenant thereto shaU not because of such employment be deemed to be an employer." MGL chapter 152, §25C(6) also states that "every state or local licensing agency shall withhold the issuance or renewal of a license or permit to operate a business or to -construct buildings in the commonwealth for any applicant who has not produced acceptable evidence of compliance with the insurance coverage required." Additionally, MGL chapter 152, §25C(7) states "Neither the commonwealth nor any of its political subdivisions shall enter into any contract for the performance of public work until acceptable evidence of compliance with the insurance requirements of this chapter have been presented to the contracting authority." Applicants Please fill out the workers' compensation affidavit completely, by checking the boxes that apply to your situation and, if necessary, supply sub -contractors) name(s), address(es) and phone number(s) along with their certificate(s) of insurance. Limited Liability Companies (LLC) or Limited Liability Partnerships (LLP) with no employees other than the members or partners, are not required to cagy workers' compensation insurance. If an LLC or LLP does have employees, a policy is required. Be advised that this affidavit may be submitted to the Department of Industrial Accidents for confirmation of insurance coverage.. Also be sure to sign and date the affidavit. The affidavit should be returned to the city or town that the application for the permit or license is being requested, notthe Department of Industrial Accidents. Should you have any questions regarding the law or if you are required to obtain a workers' compensation policy, please call the Department at the numberlisted below. Self-insured companies should enter their self-insurance license number on the appropriate line. City or Town Officials Please be sure that the affidavit is complete and printed legibly. The Department has provided a space at the bottom of the affidavit for you to fill out in the event the Office of Investigations has to contact you regarding the applicant. } Please be sure to fill in the permit/license number which Kill be used as a reference number. In addition, an applicant that must submit multiple permit/license applications in any given year, need only submit one affidavit indicating current policy information (if necessary) and under "Job Site Address" the applicant should write "all locations in (city or town)." A copy of the affidavit that has been officially stamped or marked by the city or town may be provided to the applicant as proof that a valid affidavit is on file for future permits or licenses. A new affidavit must be filled out each year. Where a home owner or citizen is obtaining a license or permit not related to any business or commercial venture (i.e. a dog license or permit to bum leaves etc.) said person is NOT required to complete this affidavit The Office of Investigations would like to thank you in advance for your cooperation and should you have any questions, please do not hesitate to give us a call. The Department's address, telephone and fax number. The Commonwealth of Massachusetts Department of Industrial Accidents Office of Investigations 600 Washington Street Boston, MA 02111 Tel. # 617-7274900 ext 406 or 1-8.77-MASSAFE Revised 5-26-05 Fax # 617-727-774 www.mass.gov/dia Date.,.,.. "pR7M14, TOWN OF NORTH ANDOVER PERMIT FOR PLUMBING ,SSACHUS� i This certifies that ....k. ....... ( f�. • • • _ has permission to perform ....................... plumbing in the buildings of ... .!'�4 .:V . i� C 7r at ....... ...... <..'. !r ? .....:^........ , North Andover, Mass. Fee: ��,f.? s204Lic. No....... ............:.•r,.:'........: PLUMBING INSPECTOR Check # 0o15)B -0-�, MASSACHUSETTS UNIFORM APPLICATION FOR PERMIT TO DO PLUMBING (Type or print) NORTH ANDOVER, MASSACHUSETTS y 0 0 9 _ /fin ,Date Building Location �' � 9 `L�� �wners Name � N"C�flr4�� / �' L Permit # Amount Type of Occupancy New 001", Renovation Replacement 1:1 Plans Submitted Yes E] No Er i01��� (Print or type) , 11 Check one: Certificate Installing Company Name IJIP �V�►— -t t� Corp. Address S p Partner. IYIK-T14u�ff rV- RusinessTelenhone 0-75'k- C,!�,-2 -?.Lobo 9 Firm/Co. Name onic ensed Plumber Insurance Coverage: Indicate theyipe of insurance coverage by checking the appropnate boic Liability insurance policy Other type of indemnity ri Bond Insurance Waiver. L the undersigned, have been made aware that the licensee of this application does not have any one of the above three insurance rgnature Owner Agent I hereby certify that all of the details and information I have submitted (or entered) in above application are true and accurate to the best of my knowledge and that all plumbing work and installations performed under Permit Issued for this application will be in compliance with all pertinent provisions of the Massach etts S �ph�rm� ode and Chap 142 of the General Laws. .own ROVED (OFFICE USE ONLY Type of Plumbing License kens U um er Master dF1Journeyman